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Prisons no place for the mentally ill
 

By Jamie Fellner and Sasha Abramsky

February 13, 2004

It is rare to find police, sheriffs, prosecutors, defense attorneys, judges, prison officials and human rights activists all on the same page. But across the criminal justice spectrum there is a striking consensus that something has gone painfully awry: the nation's jails and prisons have become mental health facilities – a role for which they are singularly ill-equipped.

At least one in six prisoners in the United States is mentally ill – well over 300,000 men and women. There are three times as many mentally ill in U.S. prisons as in the country's mental health hospitals, suffering from schizophrenia, bipolar disorder and major depression, among other illnesses.

Three decades ago few prison systems provided any mental health treatment. Most now offer something, but nowhere near enough – in quality and quantity – for the soaring number of prisoners with serious mental illness. Understaffing, insufficient specialized facilities and limited programs leave prisoners without the treatment they need.

Untreated or undertreated, mentally ill prisoners suffer painful symptoms. They rant and rave, babble incoherently or huddle silently in their cells. They talk to invisible companions and live in worlds constructed of hallucinations. They lash out without provocation and often refuse to obey orders. They beat their heads against cell walls, cover themselves with feces, and self-mutilate until their bodies are riddled with scars. Many attempt suicide; some succeed.

How is it that such desperately ill and vulnerable people are incarcerated? The quick answer is they committed a crime and were sentenced to prison by judges increasingly reluctant to declare defendants incompetent to stand trial and by juries increasingly loath to find them "not guilty by reason of insanity."

The longer answer is that the mentally ill are victims of two failed public policies.

The first is the failure of public officials to ensure an effective mental health system. Beginning in the 1960s, a process of "deinstitutionalization" freed mentally ill men and women from the bleak mental hospitals in which they had previously been dumped. But the system of community-based mental health services envisioned by the architects of deinstitutionalization never materialized. Today, community mental health services are a shambles.

People living with mental illness – especially if they are poor and homeless and have substance abuse problems – find it nearly impossible to obtain help. Untreated, they can find themselves on the margins of society, deteriorate psychiatrically and may ultimately break the law.

As criminal offenders, they then confront the second failed public policy: punitive laws, such as mandatory minimum sentences, that send people to prison even for low-level nonviolent crimes. As these laws have sent the U.S. prison population soaring to levels unimaginable in the rest of the world, so they have propelled the incarceration of many mentally ill.

Tragically, for some of the mentally ill, jail or prison may be the first time they have received any mental health services. But the more common experience of the mentally ill behind bars is to receive little or no meaningful treatment. Committed mental health professionals working in prisons acknowledge that treatment is often limited simply to medication.

Prisons were never designed for and are not now run to accommodate the unique needs of the mentally ill who find it difficult to abide by the formal and informal rules that govern prison life. Prison staff neglect them, accuse them of malingering and treat them as disciplinary problems. Other prisoners exploit and victimize them. Some correctional staff mock them, ignore their suffering or even use excessive force against them – covering them in pepper spray when they will not stop yelling, hitting them and even, in a few cases, suffocating them to death through improper methods of control.

Prisoners who break the rules because of their illnesses are punished. Even self-mutilation and attempted suicide are dealt with as disciplinary matters. Mentally ill prisoners who break too many rules, who "act out" or who are otherwise unpleasant or disruptive, are locked up interminably in segregated units or supermax prisons that provide high-security solitary confinement.

Indeed, these special segregation or isolation units are disproportionately populated by mentally ill prisoners. There they live 24 hours a day in small, sometimes windowless cells, allowed out for solitary exercise in a barren space a few times a week. They have little or nothing to do all day. Mental health treatment and programs are even worse for isolated prisoners than elsewhere in the prison systems.

Prolonged solitary confinement is hard enough for anyone. But it can be overwhelming for people whose coping mechanisms are weakened by mental illness. Many will break down completely into acute psychosis, and then have to be taken to a hospital for intensive psychiatric treatment. Once stabilized, they are returned to solitary confinement, where the cycle of their deterioration repeats.

The misery of the mentally ill in prison is not only appalling, it is unnecessary. Recommendations abound for effective steps that would strengthen community-based mental health services. There is also growing recognition of the need to divert nonviolent mentally ill offenders from the criminal justice system into treatment facilities and to ensure that dangerous offenders with mental illness are confined in secure facilities that meet their mental health needs.

Some Americans no doubt question why mentally ill offenders should receive publicly funded mental health care when countless people who have not committed a crime cannot. The answer is that everyone in the United States should have access to medical and mental health care for serious illnesses. Unfortunately, the Constitution only recognizes the state's obligation to care for those who are incarcerated. The state must meet the medical and mental health needs of those who are locked up and therefore dependent on the state for all their needs because they quite literally cannot care for themselves.

But if the law and compassion are not sufficient motivation to improve mental health services in prison, then self-interest should be. Communities are little served if mentally ill offenders are released from prison, as most eventually will be, in worse shape than when they went in.

Fellner is director of the U.S. Program at Human Rights Watch and Abramsky is consultant to Human Rights Watch. They are co-authors of the Human Rights Watch report, "Ill-Equipped: U.S. Prisons and Offenders With Mental Illness."

 http://www.sfgate.com/cgi-in/article.cgi?file=/news/archive/2003/03/06/state1557EST0112.DTL

Appeals court upholds Oregon judge on mentally ill inmates

Thursday, March 6, 2003 

(03-06) 12:57 PST SAN FRANCISCO (AP) -- An appeals court has upheld a federal judge's demand that Oregon officials promptly send all mentally ill inmates unfit to stand trial to the Oregon State Hospital. The 9th U.S. Circuit Court of Appeals on Thursday agreed with Portland-based U.S. District Judge Owen Panner that the state of Oregon violated the rights of mentally ill inmates by making them wait in county jails for weeks or months before getting a transfer to the state hospital for psychiatric care. 

Those defendants "are often locked in their cells for 22 to 23 hours a day, which further exacerbates their mental illness," the appeals court wrote, adding those inmates have a high risk of suicide. "OSH is solely responsible for the timely treatment of incapacitated criminal defendants so that they may become competent to stand trial," the appeals court said. "We are also mindful of the undisputed harms that incapacitated criminal defendants suffer when they spend weeks or months in jail waiting for transfer to OSH." 

The Oregon Advocacy Center and the Metropolitan Public Defenders Service in Multnomah County sued the state on behalf of 11 mentally ill inmates, saying the state hospital was not meeting its legal obligation to treat them within a week of being found unfit to stand trial. Panner found that inmates wait an average of 30 days and that one waited as long as 166 days. 

Panner said the delays were inhumane and hampered their rights to effective legal representation and their ability to defend themselves. In its appeal, the state said forcing the Salem hospital to accept patients -- regardless of whether a bed is available -- risks the health and safety of patients and hospital staff. In addition, the state argued that the plan would disrupt the therapeutic environment. The case is Oregon Advocacy Center v. Mink, 02-35530. 

EDITORIAL 
Life-or-Death Testing 

March 1, 2003 

Mentally disabled prisoners and the state prison officials who watch over them are in a bind that only the Legislature can fix. 

Here's how the mess developed: Just over a year ago, a federal appeals court ruled that state prisons had to abide by the federal Americans With Disabilities Act, building ramps for inmates confined to wheelchairs and assigning staff members to help blind or mentally retarded inmates who can't fill out paperwork on their own. 

To figure out who had these needs, wardens began giving a basic intelligence test. Here's where the first glitch arose. Nearly 80% of the 600 men and women on San Quentin's death row refused to take the IQ test -- no doubt on their lawyers' advice. 

A Supreme Court decision last June, which banned the execution of the mentally impaired and required states to decide who is retarded, probably figured in that decision. It also spurred California lawmakers to begin debating what the standard should be in capital cases. Which tests should attorneys use? What scores or other evidence should prove the defendant is retarded and not legally responsible for his actions? 

Estimates of the retarded prisoners on death row range wildly, from 4% to 50%. That much uncertainty, in the wake of the Supreme Court's decision, is enough to fuel every murderer's dream of cheating death. 

A capital trial eats up $1 million more on average than other criminal trials because state law requires that a defendant have two attorneys, daily trial transcripts and other expensive protections. So it's not just to protect accused people with mental handicaps that state officials need a better test. 

Two proposals are now before lawmakers. One, by Senate President Pro Tem John Burton (D-San Francisco), adopts a clinical definition of retardation that combines a low IQ score with evidence of continuing "deficits" that first appeared in childhood. Prosecutors are more comfortable with Sen. Bill Morrow's (R-Oceanside) bill, which includes the same factors but creates a presumption -- which defendants can rebut -- that any defendant with an IQ higher than 70 points is not retarded. 

California law already directs jurors, in deciding between life behind bars and a death sentence, to consider whether "the capacity of the defendant to appreciate the criminality of his conduct ... was impaired as a result of mental disease [or] defect." 

Morrow would have jurors decide a defendant's guilt before considering impairment, while Burton wants them to know whether someone is retarded at the start of the trial. 

The important matter now, however, is coming up with a clearer standard of what constitutes mental retardation. Absent that, the Supreme Court's decision will only encourage every defendant with borderline intelligence to appeal all the way to Washington. That's neither cost-effective nor just. 

LETTERS TO THE EDITOR 
Mentally Ill Need Treatment, Not Jail 

January 26 2003 

As Gov. Gray Davis considers another increase in the state's $5.2-billion prison budget, I urge him to visit the Los Angeles County Jail (Jan. 22). He should see the 2,500 inmates on psychiatric medications and an additional 100 in psychotic states, who listen to internal voices telling them to refuse medications, struggling with their illnesses. The jail's psychiatric hospital houses 50 more inmates. 

Meanwhile, Los Angeles County, with a population of 10 million, has less than 250 psychiatric beds available to treat the uninsured, unincarcerated severely mentally ill. Continuing cutbacks have downsized the number of beds tenfold. The untreated severely mentally ill respond to unseen voices and commit bizarre acts or petty crimes that result in arrest and incarceration. Jails and prisons are experiencing a tragic backlash from the misguided downsizing of the mental health system. It is time to halt this human injustice and shortsighted budgetary approach. 

Marcia Kraft Goin MD 

Prof. of Clinical Psychiatry 

USC School of Medicine 

* 

Maybe the budget crisis will finally resolve something that common sense and humanity have not been able to: We will realize that not only should we not jail nonviolent drug offenders but we cannot afford to jail them. Treatment, which is much cheaper, much more humane and much more effective, may finally get a real chance to prove its worth. 

Jim Houghton 

Encino 

Reports on facility policies related to screening of inmates at intake, conducting psychiatric or psychological evaluations, and providing treatment (including 24-hour mental health care, therapy/counseling, and use of psychotropic medications) in State prisons. This report is based on the 2000 Census of State and Federal Adult Correctional Facilities, which gathered data from 1,668 separate institutions. It provides state-by-state tabulations of facility policies and counts of inmates by type of treatment, and by facility characteristics. 

Highlights include the following: 

Nearly all State adult confinement facilities screen inmates for mental health problems or provide treatment. 

1 in 10 State inmates receiving psychotropic medications; 1 in 8 in mental health therapy or counseling. 

155 State facilities specialized in psychiatric confinement, but general confinement facilities provided a majority of treatment. 

The prevalence of mental health illnesses within correctional institutions is high, with some estimates reaching 25%. This is in part due to the transinstitutionalization that occurred in the last century. Transinstitutionalization describes the movement of mentally ill from publicly funded mental health hospitals to nursing homes and correctional institutions. The increase in mental health illnesses in prisons not only burdens the prison health care system, but it further compromises the mental health status of prisoners with mental health diseases. Mental health care providers are also in short supply within correctional institutions, despite the fact that courts have mandated the treatment of mentally ill offenders. Additionally, correctional officers, who are in charge of security issues, often lack an understanding about appropriate management of mental health illnesses (e.g.: psychosis). As such, psychotic patients may be treated as violent patients (implying intent to harm), and managed in a manner that aggravates their psychiatric condition (e.g.: with restraints, solitary confinement, isolation, etc.). 

The prison institution as it stands is not only a poor solution to managing individuals with acute and chronic mental health diseases, but also a potential contributor to the development of mental health diseases. This is best exemplified by examining prisoners placed in solitary confinement for weeks, months and years (sometimes up to 15 years!). Psychiatrists with an interest in prison mental health care note that individuals placed in solitary confinement over time may begin to have a cluster of symptoms, including psychosis, that together are known as the SHU syndrome (SHU stands for Security Housing Unit, see Voices of Thought below). While some psychiatrists believe that the mental health status of prisoners with the SHU syndrome can return to normal once released from solitary confinement, the reversibility may depend on the amount of time spent in isolation. 

Other mental illnesses (both Axis I and Axis II diagnoses) are prevalent in correctional institutions. These include, but are not limited to, bipolar disease, major depression, schizophrenia, PTSD (post-traumatic stress disorder) and addiction disorders. Due in part to the high prevalence of mental health diseases in prisons and to the isolative and disempowering nature of imprisonment, death from suicide is common in prison (NB: rates of suicide in jails much exceed rates in prisons). Suicide ranks third, behind natural causes and AIDS, as the leading cause of death in prisons. Some have estimated the rates of suicide to be 50% greater in prisons than in the community at large. Furthermore, some studies have suggested that solitary confinement, overcrowding in prisons, longer prison sentences and lengthening death rows may put prisoners at higher risk of committing suicide. 

The mental health of prisoners is also affected by the hostile prison environment. This is especially expected given than many prisoner have been subjected to a lifetime of physical, mental and sexual abuse. With the continuation of abuses in prison, including physical abuse and rape (see Voices of Thought below), prison can begin to destroy people psychologically. 

Some prisons have begun to screen inmates for mental health diseases, but no standard systematic program exists to manage this health care problem. Additionally, many prisons have cut back on funding for rehabilitation programs for prisoners with additions, even though with tougher laws more people are imprisoned secondary to drug crimes (e.g.: possession, trafficing). Overall, mental health care in prisons is in drastic need of attention.